About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review
Tower Hamlets review
CSP: Tower Hamlets
Published: June 2025
Year of death: 2021
Extracted: 6 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review highlights missed opportunities by health services to address the victim's deteriorating mental health and potential domestic abuse, including a missed referral and lack of a risk assessment. It also notes communication gaps between agencies and the vulnerability of new migrants in accessing support.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | In cases when a couple present jointly in crisis or the person with care and support needs and their carer, and the assessment is undertaken by two separate practitioners, it would be beneficial for both practitioners to discuss their assessment jointly to ensure any disclosures of a safeguarding nature are fully explored. | ELFT |
| 2 | Stepney and Wapping CMHT acknowledged the processing error on their part; the referral should have been discussed in their clinical meeting which took place on 21/12/20. Action: The following steps to prevent repeat incidents has already been commissioned: i) the victim’s referral was sent to Stepney and Wapping CMHT email distribution list when it should have been sent to the CMHT generic email for the Stepney and Wapping CMHT administration team to process. One member of Stepney and Wapping CMHT Administration Team now monitors all emails received by the Stepney and Wapping CMHT email distribution list. They will then process and cascade the referral to Stepney and Wapping CMHT ABT for screening and for clinical discussion. ii) The triaging of a referral will continue to be recorded in the Stepney and Wapping CMHT ABT book, and staff in Stepney and Wapping CMHT ABT will cross reference this with Stepney and Wapping CMHT administration team in clinical meetings to ensure no referrals are missed. iii) Stepney and Wapping CMHT Operational Lead will ensure that other referring teams/key partners have the correct referrals route to ensure compliance with GDPR when sending sensitive and confidential referrals/information. iv) Stepney and Wapping CMHT have instigated multi-agency referral meetings three days a week, where external teams such as the Psychiatric Liaison team can attend to discuss any urgent or complex referrals. | Stepney and Wapping CMHT |
| 3 | RLH Emergency Department and THGPCG Urgent Treatment Centre to review, and strengthen where required, their process for communicating discharge summaries to GP’s who operate online or beyond Tower Hamlets contracted areas. | RLH Emergency Department | THGPCG Urgent Treatment Centre |
| 4 | Babylon GP at Hand review their initial registration processes with a view to improving their communication and identification of service needs, especially from newly registering migrants, thereby ensuring a consistent offer of a “new patient health check”. | Babylon GP at Hand |
| 5 | With a view to ensuring that new patient health checks are consistently offered, NHS England review existing commissioning arrangements for NHS contracts, especially for those who offer an online service or pan-London geographic service. | NHS England |
| 6 | Home Office to consider introducing visible and sensitive information regarding domestic violence and relevant support services at all points of entry for migrants into the United Kingdom. | Home Office |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||